Implications of Frailty in Elderly Patients With Electrophysiological Conditions

Minute ventilation sensor-driven rate response as a part of cardiac resynchronization therapy optimization in older patients

BACKGROUND

Chronotropic incompetence (CI) is common among elderly cardiac resynchronization therapy pacemaker (CRT-P) patients on optimal medical therapy. This study aimed to evaluate the impact of optimized rate-adaptive pacing utilizing the minute ventilation (MV) sensor on exercise tolerance.

METHODS

In a prospective, multicenter study, older patients (median age 76 years) with a guideline-based indication for CRT were evaluated following CRT-P implantation. If there was no documented CI, requiring clinically rate-responsive pacing, the device was programmed DDD at pre-discharge. At 1 month, a 6-min walk test (6MWT) was conducted. If the maximum heart rate was < 100 bpm or < 80% of the age-predicted maximum, the response was considered CI. Patients with CI were programmed with DDDR. At 3 months post-implant, the 6MWT was repeated in the correct respective programming mode. In addition, heart rate score (HRSc, defined as the percentage of all sensed and paced atrial events in the single tallest 10 bpm histogram bin) was assessed at 1 and 3 months.

RESULTS

CI was identified in 46/61 (75%) of patients without prior indication at enrollment. MV sensor-based DDDR mode increased heart rate in CI patients similarly to non-CI patients with intrinsically driven heart rates during 6MWT. Walking distance increased substantially with DDDR (349 ± 132 m vs. 376 ± 128 m at 1 and 3 months, respectively, p < 0.05). Furthermore, DDDR reduced HRSc by 14% (absolute reduction, p < 0.001) in those with more severe CI, i.e., HRSc ≥ 70%.

CONCLUSION

Exercise tolerance in older CRT-P patients can be further improved by the utilization of an MV sensor.

EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA)

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

Comparative performance of distinct frailty measures among patients undergoing percutaneous left atrial appendage closure

AIMS

Frailty is associated with increased morbidity and mortality in patients undergoing left atrial appendage closure (LAAC). This study aimed to compare the performance of two claims-based frailty measures in predicting adverse outcomes following LAAC.

METHODS

We identified patients 66 years and older who underwent LAAC between October 1, 2016, and December 31, 2019, in Medicare fee-for-service claims. Frailty was assessed using the previously validated Hospital Frailty Risk Score (HFRS) and Kim Claims-based Frailty Index (CFI). Patients were identified as frail based on HFRS ≥5 and CFI ≥0.25.

RESULTS

Of the 21,787 patients who underwent LAAC, frailty was identified in 45.6% by HFRS and 15.4% by CFI. There was modest agreement between the two frailty measures (kappa 0.25, Pearson's correlation 0.62). After adjusting for age, sex, and comorbidities, frailty was associated with higher risk of 30-day mortality, 1-year mortality, 30-day readmission, long hospital stay, and reduced days at home (p < .01 for all) regardless of the frailty measure used. The addition of frailty to standard comorbidities significantly improved model performance to predict 1-year mortality, long hospital stay, and reduced days at home (Delong p-value < .001).

CONCLUSION

Despite significant variation in frailty detection and modest agreement between the two frailty measures, frailty status remained highly predictive of mortality, readmissions, long hospital stay, and reduced days at home among patients undergoing LAAC. Measuring frailty in clinical practice, regardless of the method used, may provide prognostic information useful for patients being considered for LAAC, and may inform shared decision-making in this population.

Impact of frailty models on the prescription of oral anticoagulants and on the incidence of stroke, bleeding, and mortality in older patients with atrial fibrillation: a systematic review

BACKGROUND

Frailty is common in older patients with atrial fibrillation (AF). Current guidelines recommend oral anticoagulant therapy (OAT) except in case of severe frailty or reduced life expectancy, but definitive evidence on which "frailty" tools may help to identify older AF patients expected to derive little or no benefit from OAT is still lacking. Some persistent uncertainties may derive from the different clinical implications that the two major models of frailty, namely the frail phenotype (FP) and the deficit accumulation model (DAM), underlie. We thus conducted a systematic review of published studies to examine the association of the presence of frailty, categorized according to the FP and DAM, with 1) OAT prescription and 2) incidence of clinical outcomes (all-cause mortality, stroke and/or systemic embolism and major or clinically relevant non-major bleeding) in patients receiving OAT.

METHODS

Embase and MEDLINE were searched from inception until May 31st, 2022, for studies using a validated tool to identify frailty in subjects aged 65 years or older with a diagnosis of non-valvular AF; only studies on patients prescribed an OAT were considered eligible for the analyses involving clinical outcomes. The protocols for each review question have been registered in PROSPERO database (CRD42022308623 and CRD42022308628).

FINDINGS

Twenty-three studies exploring the association between frailty and OAT prescription on a total of 504 719 subjects were included. Patients with increasing severity of DAM frailty showed consistently lower OAT prescription rates than non-frail patients, whereas use of OAT did not significantly differ between patients with the FP compared with non-frail subjects. Eleven studies exploring the association between frailty and clinical outcomes on a total of 41 985 individuals receiving oral anticoagulation were included. Compared with non-frail subjects, a higher risk of all-cause mortality and clinical outcomes could be observed for AF patients prescribed with OAT with severe frailty according to the DAM, with inconclusive findings for the FP. High levels of heterogeneity were observed in both groups of studies; therefore, a meta-analysis was not performed.

CONCLUSIONS

Due to the great heterogeneity among different validated frailty measures, indiscriminately relying on "frailty" should not be regarded as the gold standard for clinical decision-making about stroke prevention in older AF patients. Present findings suggest that severe frailty according to the DAM is associated with less use of OAT and increased risk of all-cause mortality, thereby representing at the moment the most reasonable tool to efficiently recognize patients with limited life expectancy and for whom there is so far scant, if any, evidence of a clinical benefit of OAT.

Frailty in patients undergoing percutaneous left atrial appendage closure

BACKGROUND

Frailty is associated with significant morbidity and mortality in older adults. Whether frailty predicts adverse outcomes after percutaneous left atrial appendage closure (LAAC) remains uncertain.

OBJECTIVE

The purpose of this study was to examine the association between frailty and clinical outcomes after percutaneous LAAC.

METHODS

We identified patients 65 years and older in Medicare fee-for-service claims who underwent LAAC between October 1, 2016, and December 31, 2019. Patients were identified as frail on the basis of the Hospital Frailty Risk Score (HFRS), a validated frailty measure centered on health resource utilization, with the cohort stratified into low (<5), intermediate (5-15), and high (>15) risk groups.

RESULTS

Of the 21,787 patients who underwent LAAC, 10,740 (49.3%) were considered frail (HFRS >5), including 3441 (15.8%) in the high-risk group. The mortality rate (up to 1095 days) were 16.1% in the low-risk group, 26.7% in the intermediate-risk group, and 41.1% in the high-risk group (P < .001). After adjusting for age, sex, and comorbidities, HFRS >15 (compared with HFRS <5) was associated with a higher risk of long hospital stay (odds ratio [OR] 8.29; 95% confidence interval [CI] 5.94-11.57), 30-day readmission (OR 1.80, 95% CI 1.58-2.05), 30-day mortality (OR 5.68, 95% CI 3.40-9.40), and 1-year mortality (OR 2.83, 95% CI 2.39-3.35). In restricted cubic spline models, the adjusted OR for all outcomes monotonically increased with increasing HFRS.

CONCLUSION

Frailty is common in patients undergoing LAAC and is associated with increased risks of long hospital stay, readmissions, and short-term mortality.

Frailty Syndrome in Older Adults with Cardiovascular Diseases-What Do We Know and What Requires Further Research?

Cardiovascular diseases (CVD) affect 60% of people over 60 years of age and are one of the main causes of death in the world. Diagnosed cardiovascular disease also triples the likelihood of Frailty syndrome (FS). FS has become increasingly relevant in cardiology and cardiac surgery and occurs in a significant number of patients with CVD, with prevalence ranging from 25% to 62%. Viewed in a multidimensional, biopsychosocial perspective, FS increases a patient's vulnerability, making them susceptible to several adverse clinical outcomes. Frailty syndrome also is a predictor of mortality in patients with CVD regardless of age, severity of disease, multi-morbidity, and disability. Frailty syndrome potentially can be prevented in patients with CVD and its early identification is important to avoid the development of disability, dependence on others and reduced quality of life. The aim of this paper is to show the relationship between FS and specific CVDs (coronary artery disease, hypertension, atrial fibrillation, heart failure) and cardiac procedures (device implantation, cardiac surgery, and transcatheter aortic valve implantation). Furthermore, we highlight those areas that require further research to fully understand the relationship between FS and CVD and to be able to minimize or prevent its adverse effects.

Atrial fibrillation: a geriatric perspective on the 2020 ESC guidelines

BACKGROUND

The Task Force for the diagnosis and management of atrial fibrillation (AF) of the European Society of Cardiology (ESC) published in 2020 the updated Guidelines for the Diagnosis and Management of Atrial Fibrillation with the contribution of the European Heart Rhythm Association (EHRA) of the ESC and the European Association for Cardiothoracic Surgery (EACTS).

METHODS AND RESULTS

In this narrative viewpoint, we approach AF from the perspective of aging medicine and try to provide the readers with information usually neglected in clinical routine, mainly due to the fact that while the large majority of AF patients in real life are older, frail and cognitively impaired, these are mostly excluded from clinical trials, and physicians' attitudes often prevail over standardized algorithms.

CONCLUSIONS

On the basis of existing evidence, (1) opportunistic AF screening by pulse palpation or ECG rhythm strip is cost-effective, and (2) whereas advanced chronological age by itself is not a contraindication to AF treatment, a Comprehensive Geriatric Assessment (CGA) including frailty, cognitive impairment, falls and bleeding risk may assist in clinical decision making to provide the best individualized treatment.

Post-operative pain following cardiac implantable electronic device implantation: insights from the BRUISE CONTROL trials

AIMS

Post-operative pain following cardiac implantable electronic device (CIED) insertion is associated with patient dissatisfaction, emotional distress, and emergency department visits. We sought to identify factors associated with post-operative pain and develop a prediction score for post-operative pain.

METHODS AND RESULTS

All patients from the BRUISE CONTROL-1 and 2 trials were included in this analysis. A validated Visual Analogue Scale (VAS) was used to assess the severity of pain related to CIED implant procedures. Patients were asked to grade the most severe post-operative pain, average post-operative pain, and pain on the day of the first post-operative clinic. Multivariable regression analyses were performed to identify predictors of significant post-operative pain and to develop a pain-prediction score. A total of 1308 patients were included. Multivariable regression analysis found that the presence of post-operative clinically significant haematoma {CSH; P value < 0.001; odds ratio (OR) 3.82 [95% confidence interval (CI): 2.37-6.16]}, de novo CIED implantation [P value < 0.001; OR 1.90 (95% CI: 1.47-2.46)], female sex [P value < 0.001; OR 1.61 (95% CI: 1.22-2.12)], younger age [<65 years; P value < 0.001; OR 1.54 (95% CI: 1.14-2.10)], and lower body mass index [<20 kg/m2; P value < 0.05; OR 2.05 (95% CI: 0.98-4.28)] demonstrated strong and independent associations with increased post-operative pain. An 11-point post-operative pain prediction score was developed using the data.

CONCLUSION

Our study has identified multiple predictors of post-operative pain after CIED insertion. We have developed a prediction score for post-operative pain that can be used to identify individuals at risk of experiencing significant post-operative pain.

The degree of frailty as a translational measure of health in aging

Frailty is a multiply determined, age-related state of increased risk for adverse health outcomes. We review how the degree of frailty conditions the development of late-life diseases and modifies their expression. The risks for frailty range from subcellular damage to social determinants. These risks are often synergistic-circumstances that favor damage also make repair less likely. We explore how age-related damage and decline in repair result in cellular and molecular deficits that scale up to tissue, organ and system levels, where they are jointly expressed as frailty. The degree of frailty can help to explain the distinction between carrying damage and expressing its usual clinical manifestations. Studying people-and animals-who live with frailty, including them in clinical trials and measuring the impact of the degree of frailty are ways to better understand the diseases of old age and to establish best practices for the care of older adults.

Non-Vitamin K Antagonist Oral Anticoagulants and Factors Influencing the Ischemic and Bleeding Risk in Elderly Patients With Atrial Fibrillation: A Review of Current Evidence

ABSTRACT

Non-vitamin K antagonist oral anticoagulants (NOACs) are a widely prescribed treatment to prevent stroke in patients with nonvalvular atrial fibrillation, and a therapy and preventative measure to prevent recurrences following venous thromboembolism. Optimal use of NOACs requires a thorough knowledge of the pharmacology of these drugs, as well as an understanding of patient factors affecting their use. The 4 NOACs-dabigatran, apixaban, edoxaban, and rivaroxaban are available in a range of doses suitable for differing indications and with a variety of dose reduction criteria. Identification of the correct dose is one of the key challenges in the individualization of treatment. Elderly patients with atrial fibrillation are at a greater risk of both ischemic and bleeding events than younger patients. Consequently, it is essential to achieve balance in anticoagulation strategies. Medication adherence to NOACs is important for safe and effective treatment, particularly in elderly populations. A growing body of evidence shows that once-daily dosing improves adherence and persistence to therapy, without having an impact on bleeding risk.

Implications of Frailty among Men with Implantable Cardioverter Defibrillators

OBJECTIVES

Frailty is associated with adverse outcomes, but little is known of the impact of frailty on patients with implantable cardioverter defibrillators (ICDs). This study sought to determine the prevalence of frailty, based on quantitative assessment, and assessed its potential impact on outcomes among community-dwelling men with ICDs.

METHODS

A total of 124 ICD-treated men presenting for a routine device clinic appointment between May and October 2016 underwent frailty assessment consisting of three components: shrinking (weight loss ≥5% during the past year), weakness (inability to rise from a chair without using their arms), and self-reported poor energy level. Patients who had no components were considered robust, those with 1 component were intermediate stage, and those with ≥2 components were deemed frail.

RESULTS

Mean age was 70.4 (±9.7) years. Of the 124 men, 31 (25%) were considered to be frail, 65 (52%) were intermediate, and 28 (23%) were robust. Frail men were older and were more likely to have symptomatic heart failure, chronic kidney disease, and hypertension (P < 0.05 for all) compared with nonfrail men. During a follow-up of 16 months, frail men were significantly more likely to die compared with nonfrail men (29% vs 5.4%, P < 0.0003). The incidence of appropriate ICD shocks (16.1% vs 6.5%) or hospitalizations (38.7% vs 23.7%) tended to be higher among frail versus nonfrail patients, but neither reached statistical significance (P = 0.10).

CONCLUSIONS

Almost one-fourth of men with ICD are frail. Almost one-third of frail ICD patients died within 16 months. It may be useful to assess frailty in patients with ICD.

Modified Frailty as a Novel Factor in Predicting the Maintenance of the Sinus Rhythm After Electrical Cardioversion of Atrial Fibrillation in the Elderly Population

Introduction

Frailty is a common geriatric syndrome that causes an elevated risk of catastrophic declines in the health and function among older adults – we hypothesized that frailty may be related to the maintenance of sinus rhythm after cardioversion.

Methods

The study sample was a group of 199 consecutive patients over 60 (average age 71.41 ± 6.99; 40.2% women) with AF who were hospitalized in order to perform electrical cardioversion. The Tilburg Frailty Indicator (TFI) was used to assess frailty before cardioversion. The six-month visit after the electrical cardioversion was a follow-up. The follow-up period for the maintenance of sinus rhythm after electrical cardioversion was 180 ± 14 days.

Results

Patients in whom cardioversion was effective had a statistically significantly lower severity of frailty syndrome (3.44 ± 1.83 vs 5.87 ± 1.12; p=0.000) and its components: physical components (2.14 ± 1.33 vs 3.62 ± 1.05 p=0.000); emotional components (0.92 ± 0.79 vs 1.29 ± 0.86 p=0.037) and social components (0.37 ± 0.56 vs 0.96 ± 0.46; p=0.000) compared to those patients in which cardioversion was ineffective. In the logistic regression, frailty (OR: 0.65, 95% CI:0.5010–0.8330; p=0.000) was observed to be an independent predictor for maintaining sinus rhythm.

Conclusion

Frailty is a novel, independent factor that can be used to predict the effectiveness of electrical cardioversion and the maintenance of sinus rhythm in the elderly population. Modifying the level of recognition in the Tilburg Frailty Indicator to a 4 improved the prediction of the effectiveness of electrical cardioversion as well as the maintenance of sinus rhythm.

The Relationship between Frailty Syndrome and Concerns about an Implantable Cardioverter Defibrillator

Frailty syndrome may cause cognitive decline and increased sensitivity to stressors. This can result in an increased incidence of anxiety and depression, and thus, concerns about life with an implantable cardioverter defibrillator (ICD). The aim of the study was to assess the impact of frailty syndrome on the increase in the number of device-related concerns after the implantation of an ICD. Material and methods: The study sample was a group of 103 consecutive patients (85 M; aged 71.6 ± 8.2) with an implanted ICD. The ICD Concerns Questionnaire (ICDC) was used to analyze their concerns about life with an ICD, and the Tilburg Frailty Indicator scale (TFI) was used to diagnose frailty. Results: In the group of patients with an ICD implanted, 73% had recognized frailty (83.3% women, 74.1% men); the average point value was 6.55 ± 2.67. The total ICDC questionnaire score for the patients with an implanted cardioverter defibrillator was 34.06 ± 18.15. Patients with frailty syndrome had statistically (p = 0.039) higher scores (36.14 ± 17.08) compared to robust patients (27.56 ± 20.13). In the logistic regression analysis, the presence of frailty was strongly associated with the total questionnaire score (OR = 1.0265, p = 0.00426), the severity of the concerns (OR = 1.0417, p = 0.00451), and device-specific concerns (OR = 1.0982, p = 0.00424). Conclusion: Frailty syndrome occurs in about 80% of patients after ICD implantation. The presence of frailty syndrome was strongly associated with concerns about an implantable cardioverter defibrillator.

Frailty and Anticoagulant Therapy in Patients Aged 65 Years or Older with Atrial Fibrillation

Background: Elderly adults with atrial fibrillation (AF) are at increased risk of frailty and thromboembolic complications. However, studies on the prevalence of frailty in AF patients and data on the relationship between frailty and the use of anticoagulants are limited.Methods: We conducted a cross-sectional study involving 500 participants. Patients aged 65 years or older were consecutively selected from the Chinese Atrial Fibrillation Registry study. The patient’s frailty status was assessed with use of the Canadian Study of Health and Aging Clinical Frailty Scale. We assessed the prevalence of and factors associated with frailty, and how frailty affects anticoagulant therapy.Results: In 500 elderly adults with AF (age 75.2±6.7 years; 51.6% female), 201 patients (40.2%) were frail. The prevalence of frailty was higher in females (P=0.002) and increased with age and CHA2DS2-VASc score (P for trend less than 0.001 for both). The factors associated with frailty were a history of heart failure (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.39‐4.14), female sex (OR 2.09, 95% CI 1.27‐3.43), and advanced age (OR 1.13, 95% CI 1.09‐1.17). Frail patients were significantly less likely to have ever been prescribed anticoagulants compared with nonfrail patients (81.7 vs. 54.9%, P<0.001).Conclusions: Frailty is prevalent in elderly adults with AF, especially in females, those of advanced age, and those with heart failure. Frailty status has a significant impact on prescription of anticoagulants for high-risk AF patients.

Frailty, Implantable Cardioverter Defibrillators, and Mortality: a Systematic Review

BACKGROUND

Evidence for the benefit of implantable cardioverter defibrillators (ICD) in preventing sudden cardiac death (SCD) in older adults is mixed; age alone may not predict benefit. Frailty may help identify patients in whom an ICD does not improve overall mortality risk.

METHODS

Structured search of PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials on 1/31/2019, without language restriction, with terms for ICD, frailty, and mortality. Frailty was defined broadly using any validated single component (e.g., walking speed, weight loss) or multi-component tool (e.g., cumulative deficit index). Each study was assessed for quality and risk of bias.

RESULTS

We identified and screened 2649 titles, reviewed 280 abstracts, and extracted 71 articles. Nine articles, including two RCTs, one prospective cohort, and six retrospective cohort studies met all criteria. The most common reason for exclusion was a lack of frailty definition. Frailty definitions were heterogeneous, including cumulative deficit models, low weight, and walking speed. Follow-up time for mortality differed: from days to > 6 years. All studies indicated that mortality was higher amongst individuals identified as frail, regardless of definition. In one RCT, slow walkers did not benefit from ICD therapy after 3 years. A cohort of 83,792 Medicare beneficiaries in an ICD registry reported higher 1-year mortality following ICD in those with frailty or dementia. Four studies reported an association between being underweight and increased mortality following ICD placement.

CONCLUSION

Existing literature suggests that individuals with frailty may not benefit from ICD placement for primary prevention of SCD.

Safety and Effectiveness of Ninjin'yoeito: A Utilization Study in Elderly Patients

Post-marketing surveillance studies of traditional Japanese medicine in Japan are limited, and currently there are no data for Ninjin'yoeito, which is often used for the elderly because of its efficacy. In this study, we aimed to investigate the post-marketing safety and efficacy of Ninjin'yoeito in elderly patients over 65 years of age in clinical practice in Japan. This survey was an open-label, non-comparative, prospective, multicenter, post-marketing survey conducted at 383 centers between February 2016 and March 2017. In the safety analysis of 808 patients, adverse reactions were reported in 25 patients (3.1%), most of whom had gastrointestinal disorders (2.1%). In the efficacy analysis, Ninjin'yoeito was found to significantly improve visual analog scale scores in fatigue/malaise and anorexia at weeks 8, 16, and 24, and weeks 8 and 24 after commencement of treatment, respectively. In addition, the Basic Checklist created by the Ministry of Health, Labor and Welfare of Japan was used as a secondary survey item. The proportion of patients expected to require nursing care significantly decreased after 24 weeks compared with the baseline in four domains (activities of daily living, motor function, oral function, and depression). On the basis of physician assessment, Ninjin'yoeito was rated as “effective” or “moderately effective” in 486 (90.5%) of 537 cases. As the checklist contains many aspects of frailty, Ninjin'yoeito might be beneficial in preventing frailty. The findings of the present study indicate the safety of Ninjin'yoeito in aged patients, although further integrated clinical trials are necessary to examine its efficacy.

Anxiety, age, education and activities of daily living as predictive factors of the occurrence of frailty syndrome in patients with heart rhythm disorders

OBJECTIVES

Frailty is one of the geriatric syndromes that are caused by subclinical impairment of many organs, leading to the loss of reserves and the ability to maintain homeostasis. Aim of the study was to assess which factors including anxiety and depression can be predictive factors for the occurrence of frailty syndrome in patients with heart rhythm disorders.

METHODS

The study included 171 consecutive patients >64 years (73.91 ± 6.72; 48.5% W) with diagnosed cardiac arrhythmias who had been qualified for pacemaker implantation. The Tilburg Frailty Indicator scale as well as the Hospital Anxiety and Depresion Scale (HADS) were used.

RESULTS

The average HADS results in the frailty group was significantly higher 7.42 ± 2.63 compared to the robust patients 6.33 ± 2.83; p =0.0019. Similar results were observed in patients with atrio-ventricular blocks (AVB): HADS-A: frail 8.23 ± 2.13 vs. robust 6.62 ± 2.27; p = 0.0036 and HADS-D: frail 8.84 ± 2.85 vs. robust 7.17 ± 2.48; p =0.0086. The multiple regression model showed that age (p =0.0023), education (p =0.0001), ADL (p =0.0001) and the severity of the anxiety (p = 0.0414) were important predictors of the dependent variable and predicted higher levels of frailty syndrome.

CONCLUSION

Anxiety, age, education and the activities of daily living can be predictive factors of the occurrence of frailty syndrome in patients with heart rhythm disorders who have been qualified for pacemaker implantation.

Frailty as a Risk Factor for Cardiovascular Versus Noncardiovascular Mortality in Older Men: Results From the MrOS Sleep (Outcomes of Sleep Disorders in Older Men) Study

Background

Frailty is associated with greater mortality; however, whether frail patients primarily die of cardiovascular disease (CVD) or non‐CVD causes is unknown.

Methods and Results

We assessed the cause of death in relation to frailty status, measured at baseline, among 3135 community‐dwelling older men in the MrOS Sleep (Outcomes of Sleep Disorders in Older Men) study. Absolute probability and risk of CVD mortality associated with frailty status were estimated with traditional methods that used censoring and newer methods that considered non‐CVD mortality as a competing risk. Of the 3135 men (mean age: 76.4±5.6 years), 475 (15.2%) were frail. During an average follow‐up of 9.2 years, 1275 (40.7%) men died, including 445 (34.9%) from CVD and 828 (64.9%) from non‐CVD causes (2 deaths unadjudicated). Both CVD and non‐CVD mortality risk increased with frailty. Cumulative absolute probability of CVD death at 10 years among frail men was 23.8% (20.2–27.6%) using the competing risk method versus 32.5% (27.3–37.8%) using the traditional Kaplan–Meier method (41.5% [95% confidence interval, 36.9–45.9%] and 48.6% [95% confidence interval, 43.6–53.4%], respectively, for non‐CVD mortality). The multivariable‐adjusted risk of CVD death among frail versus robust men was 1.38 (95% confidence interval, 0.99–1.92) using the competing risk method versus 1.84 (95% confidence interval, 1.35–2.51) using the traditional Cox proportional hazards method.

Conclusions

Among community‐dwelling older men, ≈35% of the deaths were due to CVD. Frail men were at increased risk of CVD death, but ignoring the competing risk of non‐CVD mortality overestimated their long‐term probability and relative risk of CVD death.